Medical Home and the Nurse Practitioner: A Policy Analysis

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings

INTRODUCTION

With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings.

METHODS

A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance.

RESULTS

Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level.

CONCLUSION

IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease

BACKGROUND

Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients.

OBJECTIVE

To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease.

DESIGN

In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease.

PARTICIPANTS

A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included.

MAIN MEASURES

All-cause and ambulatory care sensitive condition hospitalizations in 2018.

KEY RESULTS

There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries.

CONCLUSIONS

Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

Cost-effectiveness of nurse practitioner/community health worker care to reduce cardiovascular health disparities

BACKGROUND

Although evidence-based guidelines on the management of cardiovascular disease (CVD) and type 2 diabetes have been widely published, implementation of recommended therapies is suboptimal.

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of a comprehensive program of CVD risk reduction delivered by nurse practitioner/community health worker (NP/CHW) teams versus enhanced usual care to improve lipids, blood pressure (BP), and hemoglobin (Hb) A1c levels in patients in urban community health centers.

METHODS

A total of 525 patients with documented CVD, type 2 diabetes, hypercholesterolemia, or hypertension and levels of low-density lipoprotein cholesterol, BP, or Hb A1c that exceeded goals established by national guidelines were randomized to NP/CHW (n = 261) or enhanced usual care (n = 264) groups. Cost-effectiveness ratios were calculated, determining costs per percent and unit change in the primary outcomes.

RESULTS

The mean incremental total cost per patient (NP/CHW and physician) was only $627 (confidence interval, 248-1015). The cost-effectiveness of the 1-year intervention was $157 for every 1% drop in systolic BP and $190 for every 1% drop in diastolic BP, $149 per 1% drop in Hb A1c, and $40 per 1% drop in low-density lipoprotein cholesterol.

CONCLUSIONS

The findings suggest that management by an NP/CHW team is a cost-effective approach for community health centers to consider in improving the care of patients with existing CVD or at high risk for the development of CVD.

Patient-centered medical home model: do school-based health centers fit the model?

School-based health centers (SBHCs) are an important component of health care reform. The SBHC model of care offers accessible, continuous, comprehensive, family-centered, coordinated, and compassionate care to infants, children, and adolescents. These same elements comprise the patient-centered medical home (PCMH) model of care being promoted by the Affordable Care Act with the hope of lowering health care costs by rewarding clinicians for primary care services. PCMH survey tools have been developed to help payers determine whether a clinician/site serves as a PCMH. Our concern is that current survey tools will be unable to capture how a SBHC may provide a medical home and therefore be denied needed funding. This article describes how SBHCs might meet the requirements of one PCMH tool. SBHC stakeholders need to advocate for the creation or modification of existing survey tools that allow the unique characteristics of SBHCs to qualify as PCMHs.

Nurse Practitioners Aiding Frail Elderly Through Home Visits

By 2030, one in every eight people will be above age 65 and the worldwide population is projected to increase to one billion. Ages 85 and older are the fastest growing part of the aging population. New reforms like the Independence at Home Act and the Affordable Care Act make home care visits a more viable option. This literature review demonstrates nurse practitioners can provide home care visits as an extension of the medical home model. This will allow frail, elderly patients to receive quality patient-centered care in their home, thereby decreasing emergency room visits, rehospitalization, and workload on office-based primary care providers.

An intervention to change the approach to colorectal cancer screening in primary care

PURPOSE

The purpose of this project was to increase colorectal cancer screening (CRC) rates in the state of Nevada. Research has shown that there are several interventions for providers to use to increase CRC screening rates in practice. The Nevada Colon Cancer Partnership (NCCP) has created a toolkit to assist providers to implement these interventions in practice.

DATA SOURCES

Research has repeatedly shown that CRC screening has a great impact on the morbidity and mortality of CRC. Studies have shown that a fecal occult blood test can detect 60-85% of CRCs and a colonoscopy with polyp removal can reduce mortality by 60-90%. Multiple studies have shown that a provider's recommendation is the most consistently influential factor in cancer screening. Furthermore, offering patients a choice and encouraging active participation in health care decision making has proven to increase CRC screening rates.

CONCLUSIONS

The NCCP has collaborated with the American Cancer Society to create a web based toolkit for use by providers to change practice and screen all eligible patients for CRC. The toolkit is designed to encourage providers to decrease the morbidity and mortality of CRC and other cancers. The toolkit is useful to facilitate efforts of office-based clinicians to reduce disparities by applying screening guidelines on a universal basis to the age-appropriate population. A team approach to screening is encouraged to promote an opportunistic or global approach to assure all eligible patients are reached.

IMPLICATIONS FOR PRACTICE

As healthcare reform continues to evolve, Nurse Practitioners (NPs) will assume much of the primary care needs of our country. A preventive care model is an important aspect of the future of healthcare. NPs are in a perfect position to change the health of patients in a global way. The strategies and tools presented in this toolkit are designed to improve preventive care and assist the NP in assuring that every eligible patient receives the screening tests they need.

The Patient-Centered Medical Home: transforming primary care

The Patient-Centered Medical Home (PCMH) is a new care model that reorganizes primary care to improve access, coordination, quality, satisfaction, and comprehensive patient-centered care. Nurse practitioners should understand the PCMH concept, appraise the evidence, and become leaders in this transformation.

Primary, secondary, and tertiary prevention of cardiovascular disease in patients with HIV disease: a guide for nurse practitioners

HIV infection elevates a patient's risk for developing cardiovascular disease (CVD), due in part to direct effects of increased infection-producing inflammation and to drugs used to treat the infection, which can have untoward effects on serum lipid profiles. HIV-infected older adults often present with multiple comorbidities, including CVD, making disease management more challenging. Treatment paradigms are evolving, and nurse practitioners (NPs) are expected to play an ever-larger role in the management of HIV infection. Due to their accessibility and close patient contact, NPs are especially well suited to work with and educate patients to manage multiple risk factors. Appropriate use of primary, secondary, and tertiary CVD prevention strategies, including education to modify lifestyle risks, individualized antiretroviral treatment regimens to achieve serum lipid targets, and use of additional lipid-modifying strategies to minimize a patient's overall CVD risk profile will be important throughout the treatment lifecycle.

Community Outreach and Cardiovascular Health (COACH) Trial: a randomized, controlled trial of nurse practitioner/community health worker cardiovascular disease risk reduction in urban community health centers

BACKGROUND

Despite well-publicized guidelines on the appropriate management of cardiovascular disease and type 2 diabetes, the implementation of risk-reducing practices remains poor. This report describes the results of a randomized, controlled clinical trial evaluating the effectiveness of a comprehensive program of cardiovascular disease risk reduction delivered by nurse practitioner /community health worker (NP/CHW) teams versus enhanced usual care (EUC) to improve lipids, blood pressure, glycated hemoglobin (HbA1c), and patient perceptions of the quality of their chronic illness care in patients in urban community health centers.

METHODS AND RESULTS

A total of 525 patients with documented cardiovascular disease, type 2 diabetes, hypercholesterolemia, or hypertension and levels of LDL cholesterol, blood pressure, or HbA1c that exceeded goals established by national guidelines were randomly assigned to NP/CHW (n=261) or EUC (n=264) groups. The NP/CHW intervention included aggressive pharmacological management and tailored educational and behavioral counseling for lifestyle modification and problem solving to address barriers to adherence and control. Compared with EUC, patients in the NP/CHW group had significantly greater 12-month improvement in total cholesterol (difference, 19.7 mg/dL), LDL cholesterol (difference,15.9 mg/dL), triglycerides (difference, 16.3 mg/dL), systolic blood pressure (difference, 6.2 mm Hg), diastolic blood pressure (difference, 3.1 mm Hg), HbA1c (difference, 0.5%), and perceptions of the quality of their chronic illness care (difference, 1.2 points).

CONCLUSIONS

An intervention delivered by an NP/CHW team using individualized treatment regimens based on treat-to-target algorithms can be an effective approach to improve risk factor status and perceptions of chronic illness care in high-risk patients.